Join our Network

What Type of Provider Are You *

Solo: Medical provider, behavioral health provider, or pharmacist who will be billing under his/her own Tax ID (TIN) or Social Security Number (SSN), along with a Type 1 (individual) NPI (NOTE: If you are a person joining an existing group, please complete a New Practitioner Enrollment form located at https://www.buckeyehealthplan.com/providers/resources/forms-resources.html ) Group Practice (To obtain a new contract or add new group NPIs, services, or products under a currently contacted Tax ID.) NOTE: To add practitioners to an existing group use either the New Provider Enrollment form (fewer than 5) or the standard roster form (adding 5 or more) located on our Provider Resources page https://www.buckeyehealthplan.com/providers/resources/forms-resources.html Facility/Agency (Examples include hospitals, clinics, home health agencies, or provider types other than a provider type 21 on the Ohio Department of Medicaid Provider Master File) Waiver-only Provider (Individual or agency that only provides MyCare home and community-based services for waiver-eligible members)

Please select an option below *

I do not have a contract and need to apply I have a contract and need to add new group NPI(s), services, and/or products

Please select the products for which you wish to contract required *

Medicaid MyCare (Medicaid and Medicare duals for Ohio) Medicare Marketplace (Ambetter)

Please select the services for which you wish to contract required *

Medical Behavioral Health Medical and behavioral health Home and Community Based Services (HCBS) Waiver

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Provider First Name *

Provider Last Name *

Individual NPI * Numbers only. Enter all 9's if you don't have an NPI

Practitioner Taxonomy

Practitioner OH Medicaid * Numbers only

Practitioner Medicare

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Medicare Ambetter

Independent Provider Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Provider First Name *

Provider Last Name *

Individual NPI * Numbers only. Enter all 9's if you don't have an NPI

Practitioner Taxonomy

Practitioner OH Medicaid * Numbers only

Practitioner Medicare

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Contract Services Form (PDF)
Disclosure of Ownership Form (PDF)
W-9 (PDF)
Home and Community-Based Provider Information Form (PDF)
Home Health Services Verification (a copy of the most recent correspondence from the Ohio Department of Medicaid that lists the home health services the provider/agency is certified provide to our members)

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Home and Community-Based Provider Information Form *

Home Health Services Verification *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Ambetter Medicare

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy *

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Ambetter Medicare

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracted For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy *

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

New Practitioner Enrollment Form (PDF)
Disclosure of Ownership Form (PDF)
Standard Direct Practitioner Roster (XLS) - Complete this roster if you are submitting enrollment for several practitioners not related to a CMHC or SUD.
W-9 (PDF)

If you are only submitting the direct roster for several practitioners please us the upload option for the New Practitioner Enrollment form to attach the roster.

New Practitioner Enrollment Form *

Disclosure of Ownership Form *

Standard Direct Practitioner Roster

W-9 *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Medicare Ambetter

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Does your Organization have multiple Facility/Agency NPIs on this application? *

Yes No

Additional NPIs Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax *

Contact Email *

Provider Email *

Number of Practitioners Joining *

Number of Facilities Joining *

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Please select the services you wish to contract for* *

Behavioral Health Medicaid Waiver Medicare Ambetter

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracted For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Does your Organization have multiple Facility/Agency NPIs on this application? *

Yes No

Additional NPIs Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

Number of Facilities Joining *

New Facility Application (PDF) - Complete form for Facilities with Medical services only.
Behavioral Health Facility Application (PDF) - Complete form for Behavioral Health and for Behavioral Health Facilities with Medical services.
Disclosure of Ownership Form (PDF)
Behavioral Health CMHC or SUD Practitioner Roster (XLS) - Complete for Behavioral Health CMHC or SUD facilities if the facility has practitioners.
Standard Direct Practitioner Roster (XLS) - Complete this roster if you are submitting enrollment for several practitioners not related to a CMHC or SUD.
W-9 (PDF)

Facility Application *

Behavioral Health Facility Application

Disclosure of Ownership Form *

Behavioral Health CMHC or SUD Practitioner Roster

Standard Direct Practitioner Roster

W-9 *